The use of opioid analgesics for the treatment of chronic non-cancer pain has become a topic of intense debate in the medical community. Over the last decade there has been a significant rise in the morbidity and mortality associated with the use of these medications. In patients with mental health and substance use disorders, prescribing opioid analgesics for chronic non-cancer pain is perhaps even more challenging. Deficits in training for clinicians, together with a lack of clinical guidelines, make the management of these patients even more difficult. This article serves to provide insight into the clinical management of these patients based on personal experience as well as current established guidelines. It also highlights some of the roles that we can play to help manage this societal problem.
As a physician practicing in the field of pain medicine, I am charged with the daily responsibility of caring for people with chronic, severe pain conditions who are also living with substance use and mental health disorders. Providing safe and effective care for these people is challenging at best. Prescription opioid analgesics are commonly used to treat moderate to severe chronic pain in this patient population. With the prevalence of prescription opioid abuse, and the degree of morbidity and mortality caused by this problem1’2’3 the medical community is now trying to find ways to carefully manage pain patients, particularly those who may be at higher risk for opioid abuse. Well-meaning physicians attempt to provide adequate pain relief for their patients; however, they find themselves without the necessary clinical guidance and support. Sadly, this has lead to unfortunate outcomes for the very people who came to them seeking help.
I do not claim to have all of the answers; sometimes I find myself in a clinical quandary when it comes to managing these patients. We find ourselves in this predicament because there is a dearth of evidence-based approaches for management of patients living with the triad of chronic pain, mental health and substance use disorders. The purpose of this article is to start a conversation among healthcare providers (primary care practitioners, emergency department personnel, pain medicine specialists and mental health providers, in particular), substance abuse counselors, social workers, community leaders and clergy. I believe there is a place for all of these disciplines in the management of these patients. A multidisciplinary approach is required in order to provide the appropriate care to these patients. Hopefully, by starting the conversation we can develop a means of evaluating the efficacy of this proposed multidisciplinary approach, which will enable us to improve treatment guidelines and provide more extensive support systems for people who are grappling with the triad of chronic pain, mental health and substance use disorders.
Challenges in the hospital setting
Unfortunately, the only place where some homeless patients get medical care is the emergency department. Some of them go out of desperation and others are taken to the ED by EMS after being found in an altered state of consciousness by the authorities or other concerned citizens. In the medical system these patients are dubbed “frequent flyers”: they are in and out on the ED on a regular basis. Many of them have uncontrolled, chronic conditions, with pain being a leading symptom of these underlying medical problems. If they are admitted, the fire is temporarily extinguished: they are given a limited supply of medication, including opioids, and then discharged. There is not always a plan in place for continued outpatient medical care, so the cycle repeats itself.
In the frenzied atmosphere of inner city EDs, there is tremendous pressure to maintain a high rate of patient turnover. The goals are to diagnose, stabilize and then admit or discharge. Psychosocial issues tend to fall by the wayside. Can social workers become a greater part of the ED workflow? When these patients are identified, can they help to find them stable housing (if they do not have a fixed place of abode), get them health insurance, and then give them the opportunity to become members of an organization or healthcare system that offers primary care and mental health services to the indigent? Such organizations do exist; examples in New York City include Brightpoint Health, Care For The Homeless and Village Care. From my experience, there is a desperate need to create more of them.
Challenges in primary care practices
If these patients gain access to medical care through the appropriate channels, primary care providers are usually the first clinicians to make contact with them. Pain is a common symptom that primary care providers encounter. People with substance use and mental health disorders often engage in high risk behaviors that put them at risk of sustaining severe traumatic injuries and/or developing chronic illnesses (HIV, hepatitis, cancer) that can cause moderate to severe pain syndromes.4’5
Well-intentioned primary care providers want to provide pain relief for their patients and sometimes prescribe potent analgesics when over-the-counter analgesics are ineffective. Unfortunately, the risks involved in prescribing these medications are not always considered. One of the primary risks is the development of an opioid use disorder, which can lead to significant morbidity or mortality. An opioid use disorder, according to DSM-5 criteria, encompasses the following behavioral, psychosocial and neurophysiologic elements: impaired control over opioid use, social impairment resulting from opioid use, risky use of opioids, as well as tolerance and/or withdrawal phenomena resulting from opioid use.6 There are certain factors that put people at higher risk for developing an opioid use disorder. These factors include a personal/family history of substance abuse, a history of certain mental health disorders (major axis 1 psychopathology) and a history of childhood sexual abuse in women.7
Some persons with severe, uncontrolled mental health disorders have histories of suicide attempts; a subset of these individuals has difficulty with impulse control.8 Opioids, used to treat moderate to severe pain conditions, have the potential to be lethal if put in the hands of people with uncontrolled mental health disorders. People with active substance use disorders, particularly those who abuse central nervous system depressants (alcohol, anxiolytics, opioids/opiates), are at higher risk of fatal overdose when these medications are combined.9 Additionally, someone with an uncontrolled substance use disorder who also has chronic pain may want to obtain opioids so that the medication can be sold on the street. Some of these medications have a high street value. This creates an incentive for some patients to sell their prescribed medication in order to purchase other types of illicit or unprescribed drugs on the street.10
I have noticed two fundamental challenges that primary care providers face in busy clinics. First, a deficiency in the training required to properly evaluate and diagnose certain pain conditions sometimes makes it hard for the providers to know what they are treating. If they don’t know what they are treating, it is likely that they are not treating the condition appropriately. If opioids are being used to treat chronic pain, there should be a clearly defined condition that is likely to respond to opioid therapy. Such conditions include chronic degenerative spine and joint diseases and some nerve-related pain syndromes. Ideally, opioids should be prescribed after adequate trials of non-opioid medications have failed.
Secondly, in busy primary care clinics, providers do not have the time to implement and maintain policies and procedures that are needed in order to minimize opioid misuse, drug diversion and active substance abuse.11’12 Opioid contracts should be in place, outlining the expectations of the patient; these patients should be reevaluated frequently and be given small quantities of medication at a time. The state prescription monitoring program registry should be checked routinely, if available, to view patients’ controlled substance prescription histories. Toxicology screens should be done to determine if prescribed medications are being taken and if illegal or unprescribed medications are being used. If toxicology screens show that a patient is using illicit drugs and/or other controlled substances that are not being prescribed, a provider should have a conversation with that patient. Efforts should be made to get patient the help he or she needs if a substance use disorder is identified.
A proposed approach to patient management: the multidisciplinary model
If a patient presents with a pain condition that is not responding to simple analgesics, referral to a pain specialist is in order. If the specialist believes that the patient should be maintained on opioid therapy, the specialist and the primary care team should be working together. There should be open lines of communication between both parties. In the ideal setting, pain medicine service should be integrated into the primary care treatment model, thereby facilitating the referral process, enhancing communication between services, and ultimately improving the quality of patient care. The pain medicine team can assume the responsibilities of managing the pain medications, monitoring the patient’s clinical response to the medications, prescribing other forms of treatment, as well as implementing and maintaining the necessary policies and procedures.
Mental health providers are an integral part of the care team. The importance of controlling mental health disorders while treating chronic pain has been documented in the medical literature.13 Psychiatrists, psychologists and behavioral therapists can play a role in the management of mood and anxiety disorders. While some patients may have physically painful conditions, the presence of untreated mental health disorders such as anxiety, depression, bipolar disorder and post traumatic stress disorder can lead to increased pain sensitivity, thereby worsening the patient’s experience of pain. In the ideal setting, the mental health provider would also be trained in addiction medicine; this affords more comprehensive treatment since many patients with mental health disorders have a concomitant substance use disorder. Access to mental health care should be improved for people from all walks of life. Currently, mental health providers are overwhelmed by the demand for their services, particularly in urban centers. More funding should be made available for mental health treatment services so that patients’ needs can be adequately met.
Substance abuse counselors also play an important role in treating these patients. People with substance use disorders need constant support in order to successfully manage their disease. The counselor essentially becomes the patient’s ally. He or she provides support and reassurance for the addict, particularly at the start of the process. Counselors also provide education about the disease process and offer addicts the tools that they need to eventually become stewards of their own recovery.14 The process of recovery is different for each person. Some addicts believe that abstinence is the only way for them to truly manage their disease, while others subscribe to a harm-reduction model of recovery. In the latter model, the goal is to find ways to minimize the harmful effects of substance abuse on the addict’s psychosocial functioning. With the help of the counselor, the patient can determine which model of recovery is most appropriate and can work together with the counselor to achieve the patient’s goals.
Social workers also play a crucial role in helping patients with substance use and mental health disorders stay on the path to recovery. Many of the patients I treat have been homeless at some point in their lives. They may not necessarily have been living on the street but there have been times when they have not had a fixed, permanent place of abode. It is extremely difficult to maintain a healthy lifestyle in the setting of homelessness. Social workers can help these patients find safe and affordable housing. They can help with finding suitable daytime employment or volunteer programs, educational programs, and programs that offer food and clothing to the indigent. Social workers can also play a role in overall care-coordination, helping patients navigate complex healthcare and social service systems that can often be overwhelming for people who have limited resources.
As I continue to work with people who struggle with substance use disorders, I am beginning to realize there is a strong spiritual component to journey of recovery. The spiritual pain and yearning for a deeper connection to a higher power expressed by these patients underscore the need for spiritual counselors or clergy in the healing process.15’16 As part of the care team, they can help patients deal with the burdensome issues of anger, bitterness and guilt, which are often cited as obstacles to wellness and maintenance of sobriety.
Our civic responsibilities
The social ills that arise from prescription drug abuse have an impact on all of us. When opioids end up on the street for sale to feed someone’s addiction, we are all affected. Let us not fool ourselves into thinking that this problem is limited to the indigent living in our inner cities. Substance abuse and mental health disorders affect people from all walks of life. Suburban and rural communities are also being saddled with this issue.
I believe that we can find ways to provide safe and effective pain control for persons living with chronic, debilitating pain conditions who are also dealing with mental health and substance use disorders. Clearly a multi-disciplinary healthcare model is crucial to the success of this endeavor. Educational initiatives for healthcare providers, particularly those in training, are of great importance. Aspiring physicians, nurses and allied health professionals need to be properly trained in order to deal with the complexities of treating this patient population.
I call on community activists and local politicians to get their districts involved in the effort to fight against prescription drug abuse. There should be increased awareness of the issue on a national level so that we can start working towards this goal. If we all get involved, we can certainly make a difference. It is my hope that this article will serve as a clarion call to action.
Conflicts of Interest
This author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
- Manchikanti L, Helm S, II, Fellows B, Janata JW, Pampati V, Grider JS, Boswell MV. Opioid Epidemic in the United States. Pain Physician. 2012;15(3 Suppl):ES9–ES38 ↩
- Substance Abuse and Mental Health Services Administration. Treatment Episode Data Sets (TEDS) 2000–2010 National Admissions to Substance Abuse Treatment Services. 2012 ↩
- National Survey on Drug Use and Health (NSDUH) Series (http://www.icpsr.umich.edu/icpsrweb/SAMHDA/series/00064) ↩
- Broz D, Wejnert C, Pham HT, DiNenno E, Heffelfinger JD, Cribbin M, Krishna N, Teshale EH, Paz-Bailey G, National HIV Behavioral Surveillance System Group. MMWR Surveill Summ, 2014 Jul 4;63(6):1-51 ↩
- Parker R, Stein DJ, Jelsma J. Pain in people living with HIV/AIDS: a systematic review. J Int AIDS Soc. 2014 Feb 18;17:18719 ↩
- American Psychiatric Association. Diagnostic and statistical manual of mental health disorders. 5th ed. Washington, DC: American Psychiatric Publishing; 2013 ↩
- Jones T, Looktach S, Grant P, McIntyre J, Moore T. Further Validation of an opioid risk assessment tool: The Brief Risk Interview. J Opioid Manag. 2014 Sept-Oct;10(5):353-64 ↩
- Megan Spokas, Amy Wenzel, Gregory K. Brown, and Aaron T. Beck. Characteristics of Individuals Who Make Impulsive Suicide Attempts. J Affect Disord. 2012 February; 136(3): 1121-1125 ↩
- Häkkinen M, Launiainen T, Vuori E, Ojanperä I. Benzodiazepines and alcohol are associated with cases of fatal buprenorphine poisoning. Eur J Clin Pharmacol. 2012 Mar;68(3):301-9 ↩
- Belcher J, Nielsen S, Campbell G, Bruno R, Hoban B, Larance B, Lintzeris N, Degenhardt L. Diversion of prescribed opioids by people living with chronic pain: results from an Australian community sample. Drug Alcohol Rev. 2014 Jan;33(1):27-32 ↩
- Cone EJ, DePriest AZ, Gordon A, Passik SD. Risks and responsibilities in prescribing opioids for chronic noncancer pain, part 2: best practices. Postgrad Med. 2014 Nov; 126(7):129-38 ↩
- Nuckols TK, Anderson L, Popescu I, Diamant AL, Doyle B, DiCapua P, Chou R. Opioid Prescribing: a systematic review and critical appraisal of guidelines for chronic pain. Ann Intern Med. 2014 Jan 7;160(1):38-47 ↩
- Jackson WC. Assessing and managing pain and major depression with medical comorbidities. J Clin Psychiatry. 2013 Dec;74(12) ↩
- An Individual Drug Counseling Approach to Treat Cocaine Addiction. Chapter 5- The Role of the Addiction Counselor. Therapy Manuals for Drug Abuse: Manual 3. National Institute on Drug Abuse ↩
- Bohnert AS, Perron BE, Jaman CN, Vaughn MG, Chatters LM, Taylor RJ. Use of clergy services among individuals seeking treatment for alcohol use problems. Am J Addict. 2010 Jul-Aug;19(4):345-51 ↩
- Montgomery BE, Stewart KE, Bryant KJ, Ounpraseuth ST. Dimensions of religion, depression symptomatology, and substance use among rural African American cocaine users. J Ethn Subst Abuse. 2014;13(1):72-90 ↩